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A 4-year-old child is admitted with a high fever and lethargy. What should the nurse do first?
✔✔ Assess vital signs and level of consciousness immediately.
A toddler with a history of asthma presents with wheezing and labored breathing. What is the
nurse’s first action?
✔✔ Administer a nebulized bronchodilator as prescribed.
A 6-month-old infant is brought in for persistent vomiting and dry diapers. What should the
nurse assess for?
✔✔ Signs of dehydration including sunken fontanel and decreased skin turgor.
A child receiving IV antibiotics for pneumonia develops diarrhea. What is the most appropriate
nursing action?
✔✔ Monitor for signs of superinfection and assess hydration status.
A school-aged child complains of ear pain and fever. What finding would confirm otitis media?
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, ✔✔ Red, bulging tympanic membrane on otoscopic exam.
A 3-year-old refuses to eat and is drooling with a high-pitched cry. What is the nurse’s priority
concern?
✔✔ Possible epiglottitis; keep the child calm and avoid throat inspection.
A 5-year-old recovering from tonsillectomy begins to swallow frequently. What should the nurse
suspect?
✔✔ Possible postoperative bleeding and report to the provider immediately.
A child with a broken arm suddenly complains of numb fingers and increasing pain. What should
the nurse do?
✔✔ Assess for compartment syndrome and notify the provider right away.
A febrile infant is irritable and has a bulging fontanel. What condition should the nurse suspect?
✔✔ Meningitis and initiate droplet precautions and monitoring.
A child with cystic fibrosis has thick mucus secretions and cough. What is the nursing priority?
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